Chapter V -- Data on Health Co-ops

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   This document has been made available in electronic format
      by the International Co-operative Alliance ICA
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  REVIEW OF NATIONAL EXPERIENCE IN PROMOTING AND SUPPORTING
   THE CONTRIBUTION OF CO-OPERATIVES TO SOCIAL DEVELOPMENT:
 
  CO-OPERATIVE ENTERPRISE IN THE HEALTH AND SOCIAL CARE SECTORS
      A GLOBAL REVIEW AND PROPOSALS FOR POLICY COORDINATION
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CHAPTER V.
       SUMMARY OF AVAILABLE DATA ON HEALTH CO-OPERATIVES AND
       SUMMARY OF HISTORICAL DEVELOPMENT

       A.    Configurations of co-operative engagement in the
             health and social care sectors by type of societal
             condition

Table 1 indicates the presence, in each of the countries
affected, of the main types of co-operatively organized
enterprise (user-owned and provider-owned health co-operatives;
co-operative insurance enterprises offering health insurance; co-
operative pharmacies).  This table shows a considerable degree
of geographical clustering of affected countries.  There appear
to be strong correlations between type of co-operative
engagements, overall societal type and organizational
configuration in respect to the health and social care sectors. 

The following groups of country can be identified:

       (a)   "welfare states" in the market economies of Europe,
             with which may be included Canada and Israel;

       (b)   Japan;

       (c)   United States;

       (d)   Latin American countries;

       (e)   developing countries in Asia (India, Sri Lanka,
             Malaysia, Singapore, Philippines, Republic of Korea);

       (f)   least developed countries in Africa, Asia and the
             Caribbean (Benin, Niger, United Republic of Tanzania,
             Haiti);

       (g)   countries with transitional economies.

       B.    ESTIMATED POPULATION USING HEALTH CO-OPERATIVES

Table 2 sets out what is known, or can be reasonably estimated,
concerning the total population regularly served by both user-
owned and provider-owned health co-operatives.  The many
qualifications are set out in the notes to this table.  The
reader should consider these statistics to be only a reasonable
estimate of the order of magnitude involved, and not firm data. 

       C.    INFORMATION ON THE OPERATIONAL CHARACTERISTICS OF
             HEALTH CO-OPERATIVES

The third table in this series sets out what is known of certain
basic operational characteristics of user-owned and provider-
owned health co-operatives.  The numerous qualifications are set
out in the notes to the table.  

       D.    SUMMARY OF HISTORICAL EVOLUTION OF CO-OPERATIVE
             ENGAGEMENT IN HEALTH AND SOCIAL CARE SECTORS

As a complement to the previous analysis of development, it may
be useful to bear in mind the general course of historical
evolution - principally to be able to answer the question of
whether health co-operatives and health insurance provided by co-
operative insurers are on the upward trajectory or not.

In the nineteenth century co-operative and mutual involvement
consisted primarily of forms of social security, with some
provision of health and social care, primarily by the predominant
consumer co-operative movement.  These developments were
restricted to western, northern and central Europe.

In the first decades of the twentieth century early involvement
of the public sector in social security in some European
countries involved partnerships with co-operative and mutual
insurance enterprises.  Retail co-operative contributions to
improved nutrition and housing co-operative contributions to
improved sanitation were of major significance, given their broad
dimensions.  Engagement in health service delivery was limited:
forms of social care were more widely developed (by the consumer
co-operative movement).

During the 1920s and 1930s engagement in health service delivery
expanded in several parts of the world.  In Japan both
agricultural and consumer co-operative movements engaged in
health service delivery; in the United States farmers'
organizations played an important part in early experiments in
user-owned co-operatives and in Canada agricultural co-operative
movements supported community-based health services; in Israel
joint trade union and co-operative enterprise-based health
services were an integral part of Jewish settlement in Palestine;
in eastern Europe rural user-owned and community-based health co-
operative systems appeared and expanded significantly in
Yugoslavia, and following this model, in Poland; in India (partly
following the Yugoslav model), Sri Lanka and in China a variety
of rural community-based experiments in co-operative health
service delivery were undertaken.

During the same period government-co-operative/mutual
partnerships continued to grow as, in some European countries
elements of a welfare state were established step-by-step.  In
the United States there was an analogous partnership as part of
the New Deal support for rural co-operative development.  Only
in Spain was there a proto-co-operative provider-owned movement
having very specific characteristics.  In the USSR and Mongolia
any tendency to similar co-operative engagement (if it existed:
but co-operatives had been strong) ended with the establishment
of the particular socialist forms of enterprise-based service
provision.

Hence, at the beginning of the Second World War there were
significant foci of co-operative activity in health and social
care in a number of different parts of Asia, Europe and North
America.  They were user-owned, either as health co-operatives
or as consumer-owned retail and housing movements, and their
largely associated co-operative insurance enterprises (the
mutuals being similarly user-owned.

War-time and immediate post-war conditions profoundly affected
the continued expansion of co-operative engagement, at least in
direct service delivery and insurance.  In eastern and central
Europe and China socialist systems blocked their further
development, previous movements in China, Poland and Yugoslavia
being fully replaced by the public sector.   In some countries
of western Europe establishment of full welfare states of the
"Beveridgean model" also absorbed almost all previous co-
operative enterprise and precluded further expansion. Limitation
for this reason affected other countries during the 1950s and
1960s as the public sector expanded (as in Canada). Throughout
the developing countries with colonial or semi-colonial
experience a form of "colonial welfare" and centrally planned
public sector monopoly also precluded any incipient co-operative
engagement either in delivery or services. Indeed early
autonomous co-operative movements were themselves "co-opted" as
parastatal structures.

The only countries in which expansion occurred was the United
States, where urban-based user-owned health co-operatives were
able to develop, although simultaneously rural experiments
declined, and Japan, where in the immediate post-war conditions
the agricultural and consumer movements became stronger and
increased their commitment to health and social care. In Israel
the trade union/co-operative system became the de facto national
system.  However, on balance, the late 1940s and 1950s might be
characterised as a period when previous expansion in co-operative
movement contribution was stalled, possibly even declined
globally.

In the late 1960s a new element appeared, the provider-owned
health service delivery co-operatives in Latin America. They
expanded during the 1970s, although affected by political
upheavals in some countries, and experienced successive phases
of relationship with public sector national social security
systems as these were installed. In the United States favourable
economic conditions encouraged further expansion of opportunities
for user-owned health delivery and health insurance co-operatives
to benefit from further development of enterprise-based health
insurance and public sector programmes of support for the poor
and the elderly.

During the 1980s concern first of consumer-owned retail co-
operative movements then of agricultural co-operative movements,
joined by housing co-operatives, for environmental pollution and
improved nutrition and healthy living, led to important
contributions to broad preventive health emphases, particularly
in Japan and western Europe.

Toward the end of the 1980s and increasingly in the next decade
housing and insurance co-operatives in some countries, together
with user-owned health co-operatives, joined other movements to
call for adjustments in public sector provision, clearly becoming
inadequate in a number of welfare state and other developed
countries. In some cases public authorities agreed to open
opportunities for co-operative partnerships, as in Italy.  With
further adjustment and retrenchment in public sectors,
opportunities for co-operative enterprise increased, although in
some countries they experienced "stop-go" cycles as governments
changed and with them perceptions of the value of the co-
operative alternative.  Crisis in the mixed public/private
structures in the United States also offered chances for further
co-operative contributions.

In many developing countries during this most recent period
severe retrenchment in public sectors has offered increasing and
substantial opportunities for co-operative organization of health
and social care - but these opportunities have been difficult to
take as the co-operative movement itself had been weakened during
previous periods of too close partnership with the public sector. 
As part of restructuring, deregulation and privatization, co-
operative insurance enterprises have found new opportunities,
including provision of health insurance.  However, where
provider-owned health co-operative systems were already well-
developed the new situation has also offered major opportunities.

In the transitional economies, although opportunities for genuine
co-operative engagement appear to be very large, practical
constraints remain substantial and have so far precluded
significant development.   However, the opportunities remain, and
it is merely a matter of resolving the difficulties.

In the 1980s and 1990s, therefore, there has been an expansion
in co-operative contribution to health and social welfare.  It
has been more varied in nature than it had been prior to public
sector predominance, and, moreover, must operate in conditions
of strong private for-profit sector competition and widespread
dislocation of labour markets.

Note:        This table has been modified in format for 
             the electronic version of the document.

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                          TABLE 1  
             COUNTRIES IN WHICH THE PRINCIPAL TYPES OF
             CO-OPERATIVE ENTERPRISES ARE ACTIVE IN THE 
                     HEALTH SECTOR, 1995 
================================================================

  COUNTRY           |      PRINCIPAL TYPES OF CO-OPERATIVES
  -------                  --------------------------------
  Argentina                Primary provider-owned health co-operatives
  Belgium                  Co-operative health insurance co-operatives
                           User-owned co-operative pharmacies
  Benin                    Primary provider-owned health co-operatives
  Bolivia                  User-owned health co-operatives
                           Primary provider-owned health co-operatives
  Brazil                   User-owned health co-operatives
                           Secondary provider-owned health co-
                           operatives
  Canada                   User-owned health co-operatives
                           Co-operative health insurance
  Chile                    Secondary provider-owned health co-
                           operatives
  Colombia                 Secondary provider-owned health co-
                           operatives
                           Co-operative health insurance
  Costa Rica               Joint-provider User-owned health co-
                           operatives
                           Primary provider-owned health co-operatives
  Czech Republic           User-owned co-operative pharmacies
  Denmark                  Co-operative health insurance
  Ecuador                  Co-operative health insurance
  Finland                  Mutual organizations
  France                   Mutual organizations
  Germany                  Primary provider-owned health co-operatives
                           Co-operative health insurance
                           User-owned co-operative pharmacies
  Haiti                    User-owned co-operative pharmacies
  India                    Secondary provider-owned health co-
                           operatives
  Ireland                  User-owned co-operative pharmacies
  Israel                   User-owned health co-operatives
  Italy                    Primary provider-owned health co-operatives
                           Co-operative health insurance
                           User-owned co-operative pharmacies
  Japan                    User-owned health co-operatives
                           Co-operative health insurance
  Korea, Rep of            Co-operative health insurance
  Malaysia                 Co-operative health insurance
                           Secondary provider-owned health co-
                           operatives
  Mongolia                 Primary provider-owned health co-operatives
  Myanmar                  User-owned health co-operatives ?
  Niger                    User-owned co-operative pharmacies
  Poland                   Primary provider-owned health co-operatives
  Netherlands              Mutual health insurance
                           User-owned co-operative pharmacies
  Panama                   User-owned health co-operatives
  Paraguay                 Secondary provider-owned health co-
                           operatives
  Peru                     Co-operative health insurance
  Philippines              User-owned health co-operatives
                           Primary provider-owned health co-operatives
  Portugal                 Primary provider-owned health co-operatives
                           Provider-owned co-operative pharmacies
  Senegal                  User-owned health co-operatives
  Singapore                User-owned health co-operatives
                           Co-operative health insurance
                           User-owned co-operative pharmacies
  South Africa             User-owned health co-operatives
  Spain                    Joint provider health co-operatives
                           Secondary provider-owned health co-
                           operatives
                           Co-operative health insurance
  Sri Lanka                User-owned health co-operatives
  Sweden                   User-owned health co-operatives
                           Primary provider-owned health co-operatives
  Switzerland              Mutual health insurance
                           User-owned co-operative pharmacies
  United Kingdom           Secondary provider-owned health co-
                           operatives
                           Co-operative health insurance
                           User-owned co-operative pharmacies
  United Rep of 
       Tanzania            User-owned health co-operatives
  United States 
  & Puerto Rico            User-owned health co-operatives
                           Primary provider-owned health co-operatives
                           Secondary provider-owned health co-
                           operatives
                           Co-operative health insurance
                           Provider-owned co-operative pharmacies

It is believed that health co-operatives exist also in Australia,
but no further information is available.  



Note:        This table has been modified in format for 
             the electronic version of the document.

================================================================
 TABLE 2 POPULATION SERVED BY HEALTH CO-OPERATIVES CIRCA 1994
================================================================

   Information is presented by country, date of information,
     type of co-operative (P=provider-owned; U=user-owned), 
               Members, Users, Total users.

                                 Type   Members      Users         Total users
AFRICA
  Benin (1994)                   P      na           na            na
  South Africa (1995)            U      na           na            na
  United Republic of 
        Tanzania (1995)          U      na           na            na

ASIA/PACIFIC
  Australia
  India (1995) 1/                U      (125,000)    (750,000)     (750,000)+
  Japan:
     consumer (1995) 2/          U      1,810,000                  (7,240,000)
     agri (1993) 3/              U      8,500,000                  (22,500,000)
  Malaysia (1995) 4/             P      na           na            [2,500,000]
  Mongolia (1995)                P      na           na            na
  Myanmar                        na     na           na            na
  Philippines (1992)             U      na           na            na
  Rep. of Korea (1995)           na     na           na            na
  Singapore (1995) 5/            U      na           na            [1,200,000]
  Sri Lanka (1992) 6/            U      (22,500)     +             (+90,000)
  SUBTOTAL ASIA/PACIFIC          -      -            -             (+30,580,000)

WESTERN ASIA
  Israel (1995) 7/               U      ...          3,500,000     3,500,000
  SUBTOTAL WESTERN ASIA          -      -            -             3,500,000

LATIN AMERICA
  Argentina (1995)               P      na           na            na
  Bolivia (1985) 8/              U      440          na            na
  Bolivia (1977) 8/              P      na           na            na
  Brazil (1995) 9/               U      na           na            na
  Brazil (1995) 9/               P      na           8,000,000     8,000,000
  Chile (1992) 10/               P      na           134,500       538,000
  Colombia  (1994) 10/           P      na           144,000       576,000
  Costa Rica (1995)              P      -            na            na
  Panama (1992) 10/              U      300          na            1,200
  Paraguay (1995)                P      -            na            na
  SUBTOTAL LATIN AMERICA                                           + 9,115,200

NORTH AMERICA
  Canada (1995) 11/              U      na           na            (1,000,000)
  USA (1994) 12/                 U      na           na            (4,000,000)
  USA (1994) 12/                 P      na           na            na
  SUBTOTAL NORTH AMERICA                                           (+5,000,000)

EUROPE
  Germany (1995)                 P      na           na            na
  Italy (1992) 13/               P      na           (25,000)      (25,000)
  Poland (1996)                  P      na           na            na
  Portugal (1996)                P      na           na            na
  Spain (1996) 14/               P      -            (1,000,000) (4,000,000
  Sweden (1994)                  U      na           na            na
  Sweden (1994)                  P      na           na            na
  United Kingdom  (1994)         P      na           na            na
  SUBTOTAL EUROPE                                                  (4,025,000)

  ---------------------------------------------------------------
  Developing regions             U                                 841,200+
  Developing regions             P                                 9,114,000+
  Developed regions 15/          U                                 38,240,000+
  Developed regions 15/          P                                 4,025,000+
  ---------------------------------------------------------------
  TOTAL                          U                                 39,081,200+
  TOTAL                          P                                 12,140,200+
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ALL                                                                52,220,000+
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Notes:       Figures in ( ) indicate estimates based upon firm
             information and calculated on the basis of known
             factors.  Those in [ ] - Malaysia and Singapore - are
             "guesstimates": they are not included in regional or
             global totals.  

Information can be considered indicative only. The year to which
it refers varies. That for recent years other than 1994 is
included in the various totals without adjustment for possible
change to 1994. The total for Spain, 800,000, dating from 1988,
is included but up-dated to 1,000,000 on the basis of recent
unconfirmed reports that there has been considerable expansion
since 1988.   Information for years prior to 1988 are not
included in the totals, although shown against the relevant
countries.

Information is not available for some countries.  

Some statistics are provided for "members", sometimes without
sufficient explanation of whether the total includes or excludes
dependants of "members".  This happens also in respect to non-
member "policy-holders" or "enrolees": it is sometimes not
certain whether the numbers quoted refer only to the persons in
whose name the policy has been issued, or the total of dependants
covered by the policy.  The following notes explain and qualify
the information set out in the table:  where this is an estimate
based upon reasonable suppositions, it is provided in
parenthesis, but used nevertheless in the calculation of the
totals.

1/   Information is very limited for India. In 1995, Shushrusha
Citizens' Co-operative Hospital in Bombay had a membership of
7,624.  There were 14 other user-owned health co-operatives in
Maharashtra State: their membership is likely to be less than
that of Shushrusha, the oldest in India. An estimate of 15 x
5,000 members (=75,000) can be proposed. Indira Gandhi Co-
operative Hospital in Cochin, Kerala had 3,000 "shareholders",
presumed to be members, in 1992. There were 25 other co-operative
hospitals and 62 clinics in 1995. The former are likely to have
been smaller than that in Cochin, the oldest in the State. An
estimate of 25 x 1,000 members (=25,000) can be proposed. Health
co-operatives are also reported in Karnataka and Goa, but there
is no information on membership: it is presumed that co-
operatives are fewer and membership is smaller than is the case
in Maharashtra and Kerala, precisely because no information has
been reported. Thus a "guesstimate" of 75,000 (Maharashtra) plus
25,000 (Kerala) ( = 100,000), plus 25,000 for Karnataka and Goa
would give a total for India of 125,000 members. Information from
Shushrusha and Indira Gandhi co-operatives suggests that
"members" and "shareholders" are likely to be household-heads. 

Applying an average household size of 6 (eligible dependants are
limited to parents, siblings and children), a total of 750,000
individuals is taken as an estimate, and included in the regional
and global totals.   

To these could be added non-members to whom various community
outreach programmes were provided free or at cost: they had no
formal contractual status and were served only occasionally and
partially. No estimate of their numbers is attempted.  In very
general terms it could be said that it is unlikely that more than
one million persons are served by health co-operatives in India.

2/   The total number of members at the end of March 1995 was
1,810,000. These are identified specifically as households. Given
that most are likely to be urban residents, it seems appropriate
to apply an average household size of four persons (i.e.
including in some cases dependant resident parents), then a total
of 7,240,000 persons can be calculated.

3/   The number of members is not available. This may be because
health co-operatives within the agricultural co-operative
movement are not so much autonomous co-operative enterprises with
their own membership, as is the case of those in the consumer
movement. Rather they are facilities available by reason of
membership in the agricultural multifunctional co-operative and
specifically provided by the "welfare federation" or member
service department of the secondary level federation of these co-
operatives. Almost all rural households are in fact members of
such co-operatives, and hence can make use of these health co-
operatives.  However, as of March 1992 these enterprises were
present in only 34 of the 48 prefectures. This may express the
fact that they were not available in predominantly urban
prefectures, or not in remote prefectures with limited
agricultural sectors. Nevertheless, it is known that total
membership of the Central Union of Agricultural Co-operatives was
8.5 million, presumed to be households. Applying an average
household size of three (to reflect the demographically aged
character of rural populations and the impact of out-migration)
this would give an individual total of 25.5 million persons.  A
reasonable estimate of the numbers of individuals for whom the
services of the health co-operatives were available would be,
therefore, between 20 and 25 million, with 22.5 million being
taken as the estimate used in the regional and global totals.

4/   The provider-owned co-operative network, KDM, is now part
of the more comprehensive KOHISAT, which includes KDM, the
national co-operative insurance enterprise MCIS, co-operative
banks and consumer co-operatives. Members of all these co-
operative organizations are eligible for the services provided
by the KDM system.  The total membership in all types of co-
operative in Peninsular Malaysian in 1984, the latest year for
which information was available, was 2,292,000: with dependents,
calculated at 4 per membership this would suggest a total of
10,000,000. It can be presumed that not all members would have
access to KDM facilities. In 1988 KDM itself estimated that only
about half a million members of co-operatives would use the
network out of a potential total of three million in the
Malaysian co-operative movement. Consequently, a "guesstimate"
of 500,000 members will be used provisionally: with family
members, estimated at an additional four, the number of users
would be 2,500,000. This is an indicative total only, and is not
included in regional or global totals. 

5/   Individuals, together with their dependants, who are members
of any trade union which forms part of the National Trade Union
Council, are automatically a member of the various dental and
health care co-operatives sponsored by the Council.  In 1991
total membership of all co-operatives was 513,000, of which
233,000 in insurance and 183,600 in consumer co-operatives (with
the likelihood of some overlap between these two categories). 
A "guesstimate" of 400,000 members will be used provisionally,
suggesting total usage of 1,200,000, if average household size
is taken to be three.

6/   The only health co-operative for which membership was known
had a membership of 3,000 members in 1970:  estimates for 1992
indicate memberships of between 1,500 and 3,000 for each health
co-operative. There were 10 health co-operatives operating in
1992, suggesting a total membership of between 15,000 and 30,000
(22,500 is taken as the average). Applying an average household
size of 4, this would suggest between 60,000 and 120,000 (90,000
as an average) persons served by these co-operatives (90,000).
The numbers actually served are likely to be larger, because very
recently a number of the co-operatives decided to open membership
to all members of co-operative enterprises operating in the same
districts:  these are likely to be numerous as agricultural,
savings and credit and consumer co-operatives are well developed
in those regions of the country where health co-operatives
operate. However, there is no way of estimating the numbers
involved.

7/   In Israel in 1995 the co-operative health insurance and
services covered more than 70 per cent of the population, and
would be equivalent therefore to at least 3.5 million of the
total of over 5 million.  

8/   Information is not included in the totals as it is likely
to be out of date.

9/   The members of Usimed user-owned health co-operatives were
former contract-holders with the Unimed provider-owned health co-
operative system, and it may be presumed that they are included
within the total of 8,000,000 "users" reported by Unimed. These
are described as "health scheme users" which leaves unsettled the
question of whether they represent policy holders alone, i.e.
excluding their covered dependents, or policy holders together
with their dependants.  If the latter is the case, given that
most users were from lower middle and upper lower income
households, average household size could be taken to be five -
suggesting a user population of about 40,000,000. Unimed included
30 per cent of the country's doctors - 73,000. As the total
population was 151 million, application of the same proportion,
that is 30 per cent, would indicate 45 million persons which
accords with the estimate based on household members.  On this
basis it could be assumed that the 8 million refers to "policy
holders" and that the user-population totals 40 million. 
However, in earlier literature Unimed stated that the population
served (8 million) was "equivalent to that of the population of
Sweden", which suggests that "users" are in fact all individuals
served, both policy holders and their dependents.  This is the
total retained provisionally as the total of users.


10/   In Chile, Colombia and Panama totals are presumed to be
households represented by a member, to which a factor of four has
been applied to estimate total users.  

11/   In 1992 in Canada the 20 health co-operatives which
responded to the annual survey of all Canadian co-operative
enterprises reported an aggregate membership of 300,000.  With
dependents this would suggest a total user population of 900,000.
There were 37 co-operatives in operation in 1995.  While it is
not possible to estimate their membership, it might be assumed
that these were newer and smaller co-operatives less likely to
respond to the annual enquiry, and it is reasonable to allow an
additional user population of 100,000, making a national total
of 1,000,000.  

12/   The 1994 information provided by the National Cooperative
Business Association refers to "United States residents" and
presumably means therefore individual persons, not households. 
It identified one million users.  However, the term "member" is
usually applied to the person with whom a "health plan" has been
accepted. Dependants are clearly defined separately from the
"member".  For example, the Family Health Plan Cooperative Health
Maintenance Organization of Milwaukee defines dependants as
including spouse, unmarried children of the member or the spouse,
legally adopted children and children under legal guardianship,
foster children and even children of a dependant child.  
Consequently, the total number of users could reasonably be
estimated at membership multiplied by a factor of four. In
contrast Group Health Co-operative of Puget Sound stated
specifically in its 1994 Annual Report that it served more than
510,000 "residents" of Washington and North Idaho - presumed to
be members and "enrolees" (through enterprise-based health plans)
and their eligible dependants. This is one of the largest user-
owned health co-operative in the United States, but there are 12
others, of which Family Health Plan at Milwaukee is of the
smaller type - yet it serves 100,000 members (x 4 = 400,000).  
Consequently, it may be presumed, at least provisionally, that
the estimate of 1,000,000 by the National Co-operative Business
Association refers to "members and enrolees" excluding
dependants, so that a total of between 3.5 and 4.5 million
persons are likely to use these health co-operatives. An estimate
of 4,000,000 is used.  That this might be a correct assumption
is suggested by the fact that the predecessor of the National
Cooperative Business Association, the Co-operative League of the
United States (CLUSA) reported in 1982 a total "enrolment" in co-
operative health maintenance organizations of 706,278: this term
suggests that dependents were excluded. A growth to one million
"members/enrolees" in 12 years is feasible.  No information is
available concerning users of provider-owned co-operatives.  

13/   In 1992 users of 660 "social co-operatives" surveyed
totalled 42,000 (64 per enterprise).  The total number of such
co-operatives was about 2,000.  The total of users could be
estimated at 128,000.  However, only 13 percent were health co-
operatives, suggesting a total of 16,640.  Membership of such co-
operatives was likely to be larger than social care co-operatives
such as residential centres and "sheltered" workshops, so a total
of 25,000 is estimated provisionally.  

14/   In Spain a total of 800,000 "policyholders" was reported
for 1988: with their dependents this suggests a total of
3,200,000, applying an average household size of four. 
Subsequent, but unconfirmed reports indicated that by the early
1990s the total of policy holders had risen to 1,000,000 -- and
hence of total users to about 4,000,000.

15/   The category "Developed regions" includes North America,
Europe, Australia, Israel and Japan.  


Note:        This table has been modified in format for 
             the electronic version of the document.

===============================================================
       TABLE 3:  BASIC STATISTICS ON HEALTH CO-OPERATIVES 
===============================================================

USER-OWNED HEALTH CO-OPERATIVES
                                 Est.   No.    Members  Users Beds  Drs.
                                        Co-ops

Health co-ops, Bolivia (1985)           8      440        ?     ?     ?
Usimed health co-ops,            1993   6
  Brazil (1995)
Tignish Co-op Health Centre,
  Prince Edward Island,          1974   1      1,700      ?     ?     ? 
  Canada (1994)
New Ross Health Co-op
  Nova Scotia, Canada            1987   1      (2,500)    ?     ?     ? 
  (1994)                         
Community Health Services 
   Association members, 
   Saskatchewan, Canada
   (1995) 4/                     1962   9      10,000+      (25,000) ?   ?
Other co-op community 
   health clinics, Canada               
   (1995)                        1960s  28     ?            ?        ?      ?
Shushrusha Citizens' Co-op
  Hospital, Bombay, India
  (1992) 5/                      1969   1      7,000        ?        170   ?
Indira Gandhi Co-op 
  Hospital, Cochin, Kerala, 
  India (1992)                   1971   1      6/           7/       ?      ?
Other "hospital co-ops" in 
  Kerala, India (1992)           1949   8/     ?            ?        ?      ?
Other health co-ops 
  in Maharashtra, India 
  (1995)                         ?      14     ?            ?        ?      ?
Other health co-ops
  in Goa and Karnataka, 
  India (1995)                   ?      ?      ?            ?        ?      ?
Israel (1995)                    1926   ?      (3,500,000) ?         ?     8,000
"Medical Co-ops" members 
  of Japanese Consumers' 
  Co-operative Union, 
  Japan (1995)                   9/     118    7,240,000    none  13,028 1,605
National Welfare Fed of 
  Agri Co-ops members, 
  Japan (1993)                   1919   191    22.5     none   37,841 3,570
                                               million                   10/
COOPASI, Veraguas, 
  Panama (1992)                  1990   1      300          12/      12/   12/
NATCCO co-op, Quezon City, 
  Philippines (1992)             1992   1      ?            ?        ?      ?
Employment related trade 
  union sponsored, 
  Senegal (1980)                 1975   40     ?            ?       none   none
Dental co-op, NTUC, 
  Singapore (1995)               1971   1      ?            ?        na     none
Health care co-op, NTUC, 
  Singapore (1995)               1992   1      ?            ?        ?      ?
South Africa
Galle District Co-op
  Hospital, Sri Lanka
  (1992)                         1962   1      2,000+       13/      75     14/
Gampaha Co-op Hospital, 
  Gampaha, Sri Lanka
  (1992)                         1962   1      1,167        15/      ?      ?
Other "hospital co-ops" 
  in Sri Lanka (1995)            1932   8      ?            ?        ?      ?
Associated with small industrial 
  co-ops Tanzania (1995)         1995   5      ?            ?        ?      ?
"Interested parties partnership" 
  co-ops of various types,
  Sweden (Medikoop 
  model) (1995)                  1992   ?      ?            ?        ?      ?
Consumer-controlled co-op 
health maintenance orgs 
in the USA: (1995)                                          ?      [4,000,000]
*  Family Health Plan 
   Coop, Milwaukee, 
   Wisconsin (1995)              1979   1      100,000+     ?        --     ?
*  Group Health Co-op of 
   Puget Sound, Seattle,
   Washington (1993)             1945   1      82,000       396,000 794  1,007
*  Group Health Assoc of 
   Metro Washington D.C.         1932   1      ?            ?        ?      ?
*  Health Partners, Minneapolis-
   St. Paul (1995)               1957   1      650,000      ?        ?      550
*  Group Health Co-op of 
   Eau Claire, WI.16/
   (1991)                        1972   1      20,000       ?      none     ?
*  Group Health Co-op, 
   Madison, WI (1995)            1976   1      40,000       ?        ?      ?
*  Health Insurance Plan of 
   Greater New York              ?      1      ?            ?        ?      ?
*  Group Health Plan of 
   NE Minnesota                  ?      1      ?            ?        ?      ?
*  United Seniors Health 
   Co-op, Washington D.C. 
   (1995)                        1984   1      8,800        none    none   none


PROVIDER-OWNED HEALTH CO-OPERATIVES

Argentina (COOPRES) 
  (1996)                         1993   1      ?            10,000  ?       ?
Co-op clinics, Benin
  (1994)                         1991   10     ?            ?        ?      ?
Health co-ops, Bolivia
  (1977)                         1977   ?      ?            15,000  20   17/
Members of Unimed do                                        
  Brasil (1995)                  1967   304    na           8       1,176 73,000
                                                            million
Coop de Servicios de 
  Proteccion Medica 
  Particular (PROMEPART)/
  Institucion de Salud 
  Previsional (ISAPRE)
  Santiago de Chile              1968   ?      134,540      ?        ?      ?
  (1992)                                       (538,000)
Cooperativa Medica del Valle 
  y de Professiones de 
  Colombia (COMEVA): 
  Prepagada COOMEVA/EPS          1964   ?      144,000      ?        18/   ?
  (1995)                                       (576,000)
Health co-ops "Femec" &
  "Unimec", Colombia 
  (1995)                         ?      ?      ?            ?        ?      ?
Coopesalud, Coopesain & 
  Medicoop Costa Rica 
  (1995)                         1988   3      ?            210,000 none  95
Health co-ops, 
  Germany (1995)                 ?      3      ?            ?        ?      ?
India (SEWA)                     1080s 1       34           ?        ?      none
Social (health) co-ops
  Italy (1994)                   ?      ?      ?            ?        ?      ?
Members of Malaysian 
  Drs' Co-op [KDM], 
  Malaysia (1995)                1988   472    ?            ?        ?      ?
Enerel Dental Clinic, 
  Ulan Bator, Mongolia
  (1995)                         1994   1      ?            ?        ?      ?
Unimed de Paraguay
  (1995)                         ?      ?      ?            ?        ?      ?
Health co-op, Poland
  (1996)                         1945   ?      ?            ?        ?     ?
Lisbon and Oporto
  Portugal (1996)                ?      3      ?            ?        ?      ?
Medical Mission Group 
  Hospital & Health Services
  Co-op, Mindanao, 
  Philippines (1992)             1982   1      ?            50,000  60   ?
Autogestio Sanitaria, 
  Barcelona, Catalonia
  Spain (1988)                   1974   ?      na           194,549 ?    4,021
Lavinia, Spain (excluding 
  members in Catalonia)
  (1988)                         1976   ?      na           600,000 ?   15,375
CES.S.COOP/SANICOOP, 
  Madrid, Spain 19/
  (1992)                         1980   ?      ?            ?        ?   100(?)
Co-ops of general practitioners
  UK (1993)                      ?      30     ?            ?        none  ?
Provider-owned (doctors, 
  dentists) USA                           
  (1992)                         1982   1      ?            50,000  60   ?

JOINT USER AND PROVIDER-
OWNED HEALTH CO-OPERATIVES

Costa Rica (1995)                1993   1      none         27,000  ?       54
Spain (1988)                     1989   1      ?            194,549 ?      4,021



Notes
-----
1/  The date refers to the beginning of operation, and not to any
earlier date of registration, wherever this is known.

2/  For details see Notes to Table 1

3/  Medical staff include an unstated number of full and part
time physicians, a public health nurse, pharmacist, dentist and
two dental hygienists (The Atlantic Co-operator, vol.60, No.2,
1994, pgs.1 and 10).

4/  The Centres locaux des services communautaires in Quebec -
of which there were 160 in 1989 - were run by community boards
and employed salaried (not fee-for-service) health professional
staff. However, at least for the purposes of this paper, they
have not been considered co-operatives, because users are not
directly members with full rights of ownership and control.  In
contrast, the Community Health Services Associations in
Saskatchewan are described as "community-based and democratically
controlled by the community in which they operate" and as "some
of the oldest and most successful community-based health centres
in Canada ... organized on a co-operative basis" (L. E. Apland,
"The co-operative sector and health care in Canada", Canadian Co-
operative Association, Ottawa, Canada, January 1990, quoted in
Medical Co-op Committee of Japanese Consumers' Co-operative Union
"Medical Co-ops' Report" No 17 Medical Co-operatives in the
World, 1992, p. 131).

5/ In the Proceedings of the International Health-Medical Co-op
Forum held in October 1992 the Dean of the co-operative is
reported to have described it as a "consumer-governed"
organization, and later referred to it as "an organization of
citizens and doctors and local people interested in social work
and health care".  It is presumed that the doctors who are
members became so as representatives of the community.  They may
also be consultants who provide services to members, but this is
a distinct function, and does not imply that the co-operative is
either provider-owned or jointly-owned.  

6/ In 1992 it was reported that 50 per cent of shares were held
by the State Government of Kerala, and 50 per cent by the public. 
The total number of shareholders was 7,000. It is not clear if
these are individuals, that is user-members and health
professional staff members, although this could be presumed to
be the case.

7/ A number of large enterprises in Cochin have enroled their
employees with the hospital co-operative - it is not certain if
these are included in the total of 7,000 members.   The co-
operative also serves members of the public within the local
community.

8/ In 1992 it was stated that there were six other "hospital co-
operatives" in Kerala. In 1995, it was reported that there were
"87 health co-operative units", which comprised 25 hospitals and
62 clinics.  Possibly, these were grouped within a smaller number
of co-operatives.  

9/  In a report entitled "Materials of Medical Co-op Committee
of Japanese Consumers' Cooperative Union", distributed at the
COPAC Open Forum held at the World Summit for Social Development
in March 1994, it was stated that "Full-fledged medical business
activities carried out by co-operatives are said to have
originated with an industrial co-op (now known as agricultural
co-ops) established in the farming region of Shimane Prefecture
in 1919. The co-ops medical business spread rapidly during the
1930s, especially in agricultural areas. ... Influenced by these
developments, co-operatives in urban areas began to establish
medical societies."  However, no date was given for the
foundation of the first health co-operative within the consumer
co-operative movement.  

10/  This included part-time doctors.

11/  In 1992 the co-operative was negotiating a contract with
5,000 member strong co-operative of teachers operating in the
same province, whereby all would be able to use the co-
operative's services.

12/  The health co-operative had in 1992 no facilities of its own
and no staff doctors. The health professional members provide
services to user-members, including out-patient services in their
clinics, at agreed fees. An offer had been made to the co-
operative to purchase the only private hospital in the area.

13/  Shortly before 1992 the co-operative had decided to
establish an "associated member" category and make this available
to members of all other co-operatives in the district.

14/  Doctors from the government hospital and the medical faculty
of the local university provide consultants to the co-operative.

15/  The co-operative also serves members of the public within
the local community.

16/  Kushner (1991) includes this enterprise in a list of
"examples of active primary health care co-operatives or co-
operatives that include primary health care".  However, she notes
that, although initially established as a pure model health co-
operatives that sold voting shares, this failed to raise adequate
capital, so the group soon evolved into a prepaid, non-profit
health maintenance organization.  Nevertheless, all prepaid
members are entitled to vote in annual elections for the
consumer-run board of directors, on which only consumer members
can serve. 
 
17/ A report transmitted by the Universidad Catolica Boliviana
to the United Nations in 1977 noted that there were in 1976 18
doctors and 2 dentists attending 15,000 persons. In a Co-
operative Information Note prepared for COPAC by the Co-operative
Studies Department of this University in April 1984 it was stated
that there were 8 provider-owned health co-operatives with 444
members.   It was noted that other co-operatives, including
credit unions, also had health programmes.

18/ In 1973 the co-operative opened its own twelve story modern
hospital, but the number of beds is not known.

19/  This is the only known case of a private for profit health
sector enterprise (in dentistry) being converted into a worker-
owned co-operative by its professional employees.  A number of
other primary co-operatives were established in the Madrid
region, and at some time between 1985 and 1990 a secondary co-
operative, SANICOOP, was established.